Consent for Minor

Legal Guardian Authorization

To be completed by a parent or legal guardian when the client receiving the procedure is under 18 years of age. Both guardian and minor must sign.

Guardian Information

Guardian Full Name *

Relationship to Minor

Guardian Phone

Guardian Email *

Address

City, State, Zip

Minor Information

Minor's Full Name *

Age *

Minor's Date of Birth

Procedure(s) Consented To *

Notes

I attest that I am the legal guardian of the minor named above and that I give him/her consent to have the procedure(s) listed. I have been informed of the possible risks involved with this procedure and of its permanence.

I have been informed of the risks and the permanence of this procedure. *As a minor, I consent to this procedure. (Minor must check this box.) *

Guardian Signature *

Parent or legal guardian signs here.

Sign here with your mouse or finger

Minor Signature *

The minor receiving the procedure signs here.

Sign here with your mouse or finger